On May 24, the Kaiser Permanente Center for Total Health hosted All Systems Go! Closing the Gaps in Cancer Care, the third-annual Better Together Health event, led by the American Cancer Society (ACS) and the Council for Accountable Physician Practices (CAPP). The event highlighted patient stories, representing how coverage and accountable healthcare systems can improve survival and reduce morbidity for people living with complex conditions like cancer.

Laura Fegraus, Executive Director of CAPP led opening remarks with an overview of the state of cancer care in America. She presented research on what physicians and patients value, with evidence-based medicine, doctor-patient relationships, and care coordination topping each list. “Patients aren’t getting what they need,” she says, stressing the importance of coordinated care. “We are not there yet, and that’s why we’re here today.”

Robert Pearl, MD, Chair of CAPP (@RobertPearlMD), provided contextual framework for the event’s discussion of gaps in American health care, citing his recently published book, Mistreated: Why We Think We’re Getting Good Health Care—and Why We’re Usually Wrong. “If we cannot lower the cost increase [in health care] and do it through better quality, coordination, technology and leadership, the system will get disrupted. This is the time to change.”

Danielle Carnival, PhD, Deputy Director of the Biden Foundation’s Cancer Initiative provided a sense of hope, urgency, and change in the approach to cancer care by encouraging partnerships. Discussing racial and socioeconomic disparities, she stated: “Culturally appropriate cancer outreach efforts are needed to reach people where they are.” Dr. Carnival alluded to Cancer Moonshot in the goals of The Biden Foundation’s Cancer Initiative, which she says will “break down silos that stand as barriers for patients.”

Dr. Kanter said the detection of residual cancer in Daria’s case and so many others is “the obligation of every [PMG] physician to look at the whole patient.” In the case of barriers for change in the current health care system, he said, “There’s issues of will and physician leadership.” Dr. Bulger agreed that “physicians need to coordinate care, rather than work against each other.”

Addressing a lack of data use, Dr. Balch called on physicians to harness data. “Data creates evidence to drive action, linking science to prevention,” Dr. Seeff said. Referring to the researchable data on preventable cancer deaths, Richard Wender, MD, Chief Cancer Control Officer, ACS, stated an increase in survival rates requires “a need to invest in a disproportionate way what is proven to work.”

Dr. Seeff reminded that in “cancer survivorship, it’s key to remember the human element.” There are several factors blocking patients’ access to cancer, outside of treatment, such as logistics, transportation, and food security, among others, Dr. Balch warned.

Office of the National Coordinator Deputy Assistant Secretary for Health Technology Reform John Fleming, MD, gave a keynote address on policy. His suggestion that “Every American should have a single, unified electronic head record available in the cloud,” from anywhere, at all times, for all involved physicians to access was met with approval from event audience.

While the outlook on American healthcare is uncertain, the panel and speakers are hopeful. They agreed with Dr. Kanter that for now, “Nothing is more important than the issue of health care access and coverage.” For more information on Better Together Health, click here.

“It will not be possible to move the country toward accountable, value-based care without strong physician leadership at all levels of the organization.”

This statement was made by Robert Pearl, M.D., CEO of the Permanente Medical Group and the Mid-Atlantic Permanente Medical Group. Dr. Pearl recently moderated a panel at the CAPG Colloquium held in Washington, DC, on September 29, 2016.

The panel, “Physician Leadership in the Movement Toward Accountable Care,” was hosted by the Council of Accountable Physician Practices (CAPP) and featured CAPP leaders discussing best practices in recruiting, training and developing physician leaders.

“Healthcare systems should view physician leadership as a capital investment for the future with huge ROI,” said Dr. Pearl, who also serves as the chairman of the board of CAPP. “The CAPP medical groups are committed to sharing their considerable experience to help all provider organizations face the challenges ahead.”

Over the course of the discussion, the panel touched on key aspects of their physician leadership development approaches. All agreed that leadership development starts at the moment of recruitment into the organization.

“Every physician is a leader. We start with that assumption,” said Marc Klau, MD, Assistant Medical Director of SCPMG. “Take every physician on as a leader and then expand their capability, because you never know when you will need them.

Dr. Klau described how SCPMG’s expansive geography allows for unique leadership development opportunities because programs begin at the medical center level. He explained that each medical center allows emerging physician leaders to build programs that work toward the Triple Aim goal. He stressed that this display of clinical excellence is critical to growing as a physician leader, because it builds trust among peers.

Dr. Klau also discussed how SCPMG’s leadership programs are geared toward training leaders in Permanente culture, not just administrative practices.

“It’s not about learning to log in to our electronic health record,” he said. “It’s about anchoring people in our history, quality expectations and developing communication skills.”

The panelists overwhelmingly agreed that physician leaders must possess emotional intelligence to be effective.

“The best leaders are going to be visionary but anchored in reality,” said Dr. Klau. “People who have a passion for doing something are the people who will move and change the world.”

The panelists agreed that physicians who are aspiring to lead their health systems or who think they might want to take on a more comprehensive role should start small. Emerging physician leaders could join clinical improvement committees or the first stage of a leadership program to determine if the track is right for them.

Dr. Robert Pearl, MD, Chairman and CEO of The Permanente Medical Group and the Mid-Atlantic Permanente Medical Group, was recently interviewed by Bloomberg BNA’s Alex Ruoff about a primer on health care issues produced by the Council of Accountable Physician Practices (CAPP), which Dr. Pearl chairs. The primer was written for political candidates at all levels of elected office, and encouraged candidates to think beyond the success or failure of the Affordable Care Act (ACA) when considering health care policy.

The primer identified three issues that all elected officials should learn about to make the best policy decisions for their constituents. These include value-based reimbursement for doctors and hospitals, robust and coordinated use of health information technology, and improved quality measurement and reporting.

Dr. Pearl said in the article that neither Democratic candidate Hillary Clinton or Republican Donald Trump has spent much time discussing these topics during their speeches or in their official platforms.

“Both candidates have commented on the exchanges and the price of drugs, but there hasn’t been a discussion about the big changes needed in health care,” he said.

According to the article, although Medicare is already moving doctors into value-based payment systems, CAPP wants the candidates to commit to accelerating the pace of change and push for global capitation in which doctors are paid a flat rate based on the size and health of their patient population instead of for each service they provide.

The article goes on to assert that this shift could help to reduce the annual growth in Medicare spending, which according to the 2016 Medicare Trustees Report, is expected to increase as a portion of overall gross domestic product from its current level of 3.6 percent to 5.6 percent by 2040.

Dr. Ameya Kulkarni is an interventional cardiologist with the Mid-Atlantic Permanente Medical Group.

No one wants to spend their days in a hospital room. For the more than 5 million people in America who live with heart failure, a hospital stay is an unfortunate fact of life. In fact, it is estimated that there are over 1 million hospitalizations for people with this condition every year. The burden on patients, their families and their communities is immense. And the cost of this care is so high that there is a currently a national focus on trying to drive down admissions to the hospital for heart failure.

The Kaiser Permanente Center for Total Health regularly updates the information in our displays in collaboration with our health systems partners in Kaiser Foundation Health Plan and the Permanente Medical Groups. The Q1 2016 update focuses on Quality & Expert medicine, as led and delivered by the Mid-Atlantic Permanente Medical Group.

So far, the ideas on how to solve this problem mostly treaded old paths – exchanging hospitalizations for more doctor office visits. We know that patients end up in the hospital when they fill with fluid. Signs of this fluid buildup (increased weight, decreased activity) usually show up well before the need for a hospitalization. Our solution so far has been to have patients come to the doctor’s office more frequently for weight and activity checks. Although cumbersome for both the patient and the clinical care team, at least coming to the doctor every week keeps these patients out of the hospital.

It does not, however, make patients happier. Although no one wants to be in a hospital, few long for frequent battles with traffic only to pay a copay and wait for a doctor to review their weight and activity and make a small medication adjustment.

The innovation team at the Mid-Atlantic Permanente Medical Group – the independent medical group that exclusively serves Kaiser Permanente members in Washington, D.C., Maryland, and Virginia – has a vision of using 21st century technology to keep a close watch on our patients without the burdens of the traditional face-to-face visit.

We know that an early signal that a patient with congestive heart failure (CHF) will land in a hospital is a decrease in activity or an increase in weight. So we are giving our patients connected monitors that measure these parameters and send them to the care team automatically. We do the rest. When patients are doing fine, we don’t bother them. But when we get a signal that things aren’t going so well, we can reach out to make an adjustment before the fluid retention gets out of hand.

A new study from Imperial College London published in April 2016 had startling findings: “There are now more adults in the world classified as obese than underweight.”

The study, which pooled data from 183 countries, found that “the number of obese people worldwide had risen from 105 million in 1975 to 641 million in 2014”. While the World Health Organization previously set a goal to have no rise in obesity above 2010 levels by 2025, the new research predicts that the probability of reaching this goal is “close to zero.”1

Negative health outcomes and obesity trends have coincided with other major trends. Consider the correlation between the growth in American obesity during a period over which Vehicle Miles Traveled (VMT) have persistently increased nationwide. In recent years, this trend has halted, with VMT actually decreasing.

This dip has been attributed to a variety of factors, including the Great Recession, the recent growth in urban populations (which for the first time since the 1920s exceeded the growth of suburban areas), a diversification of transportation options (think car share, uber, lyft, and real time transit information) among other factors.

More recent data indicates that VMT growth rates could be shifting to pre-recession rates, and it is yet to be seen if the reduction in driving will last.

Regardless, the growth in obesity levels has steadily increased during this period: “Over the past 35 years, obesity rates have more than doubled. The average American is more than 24 pounds heavier today than in 1960.”

What has attributed to this incessant rise in obesity?

One factor is the fundamental change to the American built environment that has occurred over the past 100 years, which encourages sedentary lifestyles. At the turn of the 20th century, most people lived in farming communities (60 percent) and worked labor intensive jobs, while 28 percent lived in dense, walkable cities. Relatively few people at this time, about 12 percent, lived in “suburban” areas.2

By 2000, the landscape of America had drastically altered, with the majority of Americans (52 percent) living in sprawling suburban communities designed to move vehicles.

Although correlation is not causation, that our culture is so dependent on the automobile for daily life has impacted, to some degree, our health and our well-being. Most Americans now live in places where it is uncomfortable to walk or bike for most trips, making driving the most viable option for transportation. Multiple data sources indicate that a majority of people, 76 percent (according to 2013 data) drive alone to work.

Cities and states across the country are well aware of the obesity epidemic. As a result, they are working to prioritize bicycling and walking infrastructure development to provide more healthy travel options. Doing so represents an attempt to halt the growth of obesity through transformative tools such as complete streets programs and safe routes to school programs.

Transportation planners and engineers rely on data to develop better infrastructure and to prioritize investments. Longitudinal data on vehicular travel is robust, but equivalent data for walking and bicycling is almost non-existent. The ability to access more robust data helps communities:

Determine where investments in walking and biking infrastructure are most needed

Assess changes over time, draw conclusions about the impact of new facilities, and improve the design of future facilities

Understand crashes involving people walking or bicycling more than is typically possible with crash data alone

Quantify the benefits of walking and biking, which ultimately makes active transportation projects more competitive for funding

Fortunately, there are a number of current and emerging technologies that can capture and process non-motorized data efficiently and economically. After researching several of these technologies,Alta Planning + Design, a company that designs and implements bicycle and pedestrian infrastructure for cities and institutions, is excited to announce the publication of the Innovation in Bicycle and Pedestrian Counts white paper.

Learn more about Alta Planning and Design’s findings tomorrow in Part 2.

Responding to the comprehensive needs of children and adolescents who have experienced sexual violence can be daunting. Survey data from eight countries show that approximately one in four girls and one in seven boys experience sexual violence as children.

There is growing consensus on the need for integrated services – clinical, social, and community— and for clear referral pathways between these services to meet the complete needs of the child/adolescent beyond the clinical exam. These linkages are critical to meet the short and long-term medical, psychosocial, safety/protection, legal/justice, and other social needs of children and adolescents who have experienced sexual violence.

However, there is limited global guidance on how a referral system for children and adolescents who have experienced sexual violence should function, and/or what follow-up such a system should include.

How do we respond to something so sensitive that requires multi-sectoral support and funding, in environments that have few resources?

Better understand and facilitate linkages with critical social and community services for comprehensive care of children and adolescents who have experienced sexual violence and exploitation beyond the clinical exam

Take additional steps to help children and adolescents receive the information and support they need

Contribute to changes in sociocultural norms that perpetuate a culture of violence and silence that can also increase HIV risk and vulnerability.

Among other topics, the Guide:

Includes an overview of the minimum services children and adolescents who have experienced sexual violence and exploitation need

Describes the major service providers for children and adolescents who have experienced sexual violence and their coordinating roles; offers detailed guidance on setting up a referral pathway and facilitating coordination between communities and facilities

Presents program highlights from around the world on efforts to address sexual violence.

Children and adolescents who experience and seek services for care, treatment, and support for sexual violence may enter the system at any number of points: a lower-level health facility, a hospital, a nongovernmental organization office, a police station, a school, a church or mosque, another community point or by reporting a violation to a community leader or traditional court mechanisms.

To ensure that children and adolescents receive the services they need, all stakeholders in this system must coordinate their service provision and should be aware of what resources are available in their communities.

About the author:

Marcy Levy is a senior technical advisor for JSI and the AIDSFree Project. The Strengthening High Impact Interventions for an AIDS-free Generation project is managed by a consortium of partners including JSI Research & Training Institute, Inc., Abt Associates Inc., EGPAF, EnCompass, LLC, IMA World Health, the International HIV/AIDS Alliance, Jhpiego Corporation, and PATH.

Interview with Robin Guenther, Architect and Expert in Sustainable Design

Robin Guenther doesn’t just design pretty hospitals. She designs spaces that resonate health and well-being from the ground up.

As the sustainable healthcare leader at global architecture and design firm Perkins+Will, Guenther understands that every aspect of health and sustainability needs to be considered in the design of hospitals and healing spaces. It’s not enough to build hospitals with the latest healthcare technology. Rather, we need to be considering all aspects of a hospital’s building design and how that design lends itself to healing people and healing the planet.

“There’s something ironic about physicians, nurses and caregivers working to keep people alive and healthy in buildings that feel dead and that are built of materials that contribute to disease,” explains Guenther. “We need to build healthcare facilities that inspire health, that are built with healthy materials, that use as little energy as possible and that connect us with our living environments.”

Guenther was one of the keynote speakers at the CleanMed conference in Portland, Ore. this year. The conference is held annually for hospital and business leaders working at the forefront of sustainable healthcare.

In this video, Guenther shares some of her insights on the current trends in sustainable healthcare design – from building low-energy and net-zero hospitals to designing for the impacts of a changing climate.

Editor’s Note: May is Mental Health Month, and Kaiser Permanente has joined forces with theNational Council for Behavioral Health, Mental Health America, and other organizations across the country to help raise awareness around the importance of early identification of symptoms and reducing stigma around mental illness. Guest blogger Christina Kerby spoke with several people from the Kaiser Permanente Care Management Institute for the following post.

When we think about cancer, heart disease, or diabetes, we begin with prevention. When people begin to show signs such as a persistent cough, high blood pressure, or high blood sugar, we try immediately to identify the problem and reverse these symptoms. We don’t ignore them. In fact, we develop a plan of action to reverse and sometimes stop the progression of the disease. So why aren’t we doing the same for individuals who are dealing with potentially serious mental illness?

Mental health conditions should be addressed long before they reach the most critical points in the disease process. One of the best ways to identify early symptoms is through routine use of tools in primary care settings that can aid in diagnosis and gauging effectiveness of treatment. One such tool is the Patient Health Questionnaire-9, or PHQ-9, a brief questionnaire that can be administered by any clinician as part of routine office visits or online via secure messaging.

The PHQ‐9 has been shown to be a useful tool not only for assessment and diagnosing, but also for monitoring treatment of major depression. To understand how this tool can be best used across the continuum of care, and how consistent use can improve depression control rates, we turned to our Seattle-based affiliate Group Health, which has experienced excellent results through its Depression Care Program.

To better understand Group Health’s success, we interviewed patients and care providers, collected and analyzed performance data, observed care settings, and pulled together the results in this case study.

“We found that Group Health consistently outperforms external benchmarks for six-month remission rates after a new diagnosis of depression,” said Andrew Bertagnolli, PhD, Senior Manager for Behavioral Health at Kaiser Permanente’s Care Management Institute.

Kaiser Permanente’s use of the PHQ-9 to assess symptom severity at the beginning of a depression episode has improved, helped by tools within our electronic medical record to enable easier administration and capture of the PHQ-9. The Northwest Region, in particular, has seen an improvement from 20% to 77% of members being assessed at the beginning of their episode.

“This is powerful data that shows the integration of behavioral health into primary care settings improves outcomes for patients by helping to identify symptoms early on,” said Dr. Bertagnolli.

In addition to improving assessment rates and outcomes, we can use Group Health’s performance to inform the way we spread and operationalize practices that improve care and outcomes for our members and patients. The case study examines how to generate will, change a culture, and support and sustain the practice. The case study is a rich resource for other organizations also wanting to learn from a leading performer in depression care.

“Kaiser Permanente’s integrated system enables us to spread leading practices quickly,” said Scott Young, MD, of the Permanente Federation. “This case study represents our commitment to learning and sharing for the benefit of providers and patients everywhere.”

In recognition of National Healthcare Decisions Day on April 16, we spoke with Dr. Dan Johnson, national physician lead for palliative care at Kaiser Permanente’s Care Management Institute, to demystify health care decision making and understand the importance of advance care planning.

Q: What is advance care planning and why is it so important?

A: Advance care planning (ACP) is the process of planning for future medical decisions. ACP enables you to better inform and direct your care in situations where you’re not able to speak for yourself. Importantly, ACP:

starts with reflection and conversation around personal values, goals, and beliefs;

includes others – loved ones, family members and your health care team; and

often results in completion of an advance directive – a written plan for future medical care regarding goals of care or desired treatments for a possible or probable event.

It’s not easy to think about serious illness, much less plan for it. Yet we must. Advance care plans protect us when we cannot speak for ourselves. It’s a precious gift to our loved ones. Instead of guessing, our families and doctors have much needed guidance to ensure the right care.

Q: Why do I need to do this, especially if I’m healthy?

A: Accidents and serious illness sometimes strike suddenly. Terri Schiavo never planned for a cardiac arrest at age 26. Without prior plans or an appointed decision maker, her health care team and family were left to guess her wishes around prolonged life support. Sadly, the guessing irreparably divided her family.

Not everyone is ready to fill out an advance directive. Having a conversation with your health care team is still helpful in these instances to communicate the things that matter most to you. Appointing an agent – someone to speak for you if you cannot speak for yourself – is a crucial step at any time, even when you’re not fully sure of your wishes for future care.

Q: I already filled out an advance directive. Do I need to do this again?

A: Possibly. This question is best answered by your doctor and health care team. For example, sometimes documents filled out in one state are not valid in all states. Documents completed in the absence of informed discussions are rarely helpful (and often confusing). I would recommend re-doing your advance directives if you know your plans have changed or if you did not include your loved ones in your original planning discussions.

Q: Do I need to use any specific forms for an advance directive — from a particular care provider, for example?

A: No. For instance, many Kaiser Permanente regions are beginning to offer our members advance care planning classes or one-on-one facilitated sessions — but no one is required to use a Kaiser Permanente advance directive form. Talk with your doctor and health care team to learn about your options.

Anyone can use Kaiser Permanente forms. Regardless of the form you use, be sure to discuss your values, preferences and documents with your health care team.

Q: How can I be reassured that the health care provider will look at my advance directive and follow my wishes?

I’d recommend two things. First, insist on including your health care team in discussions. Your physician and other providers will help you ask the right questions, explore your values, and pose important “what ifs” to help you communicate treatment preferences. The team will help you complete a written directive and assure that directive is correctly stored in your medical record. Second, include your loved ones. Ensure your appointed “agent” is present during actual conversations and completion of directives. Give copies of completed directives to your doctor, agent and other loved ones so that those who are most important to you know your wishes.

A: What happens if I want to update my advance directive? Do I need to fill out a new one?

Remember, advance care planning is not a single event. Rather, it is a series of conversations that start when we’re healthy and continue throughout our lives. Yes, refresh your discussions and directives with major changes in your relationships, personal values or health status. Your doctors (in concert with your appointed health care agent) will always use the most recently completed documents to direct your care.

To learn more, check out this article on the Kaiser Permanente Share site, or find additional resources available from NHDD.

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